Job Information

The mission of The University of Texas M. D. Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.

Summary

The primary purpose of the Denials Coordinator-Audit Coordinator position within the PBS department is to utilize one's clinical expertise, insurance knowledge, business know-how, and high level communication to analyze patients accounts and invoices to assist in the resolution for retrospective approval for denied services and possibly continued access needs or retrospective review and audit patient accounts and to complete a Defense Audit.

Key Functions

Analyze invoices and accounts in patient accounting system to prepare for appeal of third party payer denials (for the Denial Coordinator role). Utilize Explanation of Benefits and Remittance Advises to verify denial and identify possible avenues of appeal. Will contact third party payers, insurance medical directors, case management, and utilization review to request reconsideration and/or appeal of claims requiring clinical intervention and assure that one provides comprehensive data to justify appeals. Contact may be by phone, fax, written, and/or in person.

Evaluate and audit medical records to support in Defense Audits (for the Nurse Audit role). Reviews to support that services were indeed provided and billed accordingly. Will review for overcharges and for charges that need to be added. Will review findings with outside auditors.

Assist non-clinical staff with medical information and interpretation of records.

Assures update and/or documentation in patient accounting system as indicated, relating to insurance, demographics, notations, and service codes. Inputs data accurately, efficiently, and consistently. Must assure documentation in patient accounting system as it relates to potential future care needs if indicated.

Communicates with the Manager and Director of the Revenue Billing department to assure reporting of specific issues as it might relate to future care needs for communication back to designated Business Center.

Communicates with the Director of Revenue Billing to assure that the Managed Care Department is aware of issues as it relates to present contract performance and/or difficulties.

Demonstrates thorough knowledge of third party payers' claim requirements, UB04, and HCFA1500 requirements by payer, computer capabilities as related to claim production and admitting/medical records as they affect claims. Demonstrates thorough knowledge of third party payers' EOB' s (Explanation of Benefits) and ability to recognize areas for appeals and specific time limitations for appeals or for audits.

Demonstrates thorough understanding of applicable insurance websites, claim logic guidelines, and insurance guidelines for medical necessity review including M&R and Interqual. Also should demonstrate a working knowledge of ICD-10 and CPT. Must be able to review medical policies and literature to apply to denials and appeals.

Maintains current knowledge of oncology clinical processes and outcomes. This would include access and understanding of clinical trials and resources for information needed as it relates to the clinical trials.

Performs related business office responsibilities as assigned with minimum supervision, exhibit innovation and good judgment as well as a thorough knowledge of ethical and legal billing procedures.

Follows hospital and department policies and procedures and observes confidentiality in all matters.

Takes an active role in facilitating a team approach to functions within the department and provides positive suggestions and ideas to the team for improved revenue recovery.

Performs other duties as assigned.

REQUIREMENTS

Experience

Required: Five or more years' experience in clinical nursing and at least one year of experience in utilization review, Case Management, and/or auditing.

Preferred: Two or more years' experience in oncology nursing and five years of experience in utilization review with external payers within a Healthcare or Insurance setting or nurse auditor preferably from a hospital setting.

Education

Required: Graduation from an accredited school of Registered Nursing.

Preferred: Bachelor of Science in Nursing (BSN) or above

License/Certification

Required: Current license to practice professional nursing in the State of Texas. (RN)

Basic Life Support (BLS) or Cardiopulmonary Resuscitation (CPR) certification.

Preferred: American Heart Association Basic Life Support (BLS), ACLS (Advanced Cardiac Life Support) or PALS (Pediatric Advanced Life Support) certification as required by patient care area.

It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html